What is the recommended stepwise management for atopic dermatitis, including emollient use, trigger avoidance, topical corticosteroids, calcineurin inhibitors, and systemic therapies?

Stepwise Management of Atopic Dermatitis (Eczema)

All patients with atopic dermatitis require daily emollients and trigger avoidance as foundational therapy, with treatment escalation based on disease severity using topical corticosteroids as first-line anti-inflammatory agents, followed by steroid-sparing topical calcineurin inhibitors, and ultimately systemic therapies for refractory cases. 1

Foundation: Basic Therapy for All Severity Levels

• Apply emollients liberally and frequently (at least twice daily, immediately after bathing) to all affected and unaffected skin to maintain skin barrier integrity 1
• Identify and avoid triggers including allergens, irritants (fragrances, wool, harsh soaps), temperature extremes, excessive sweating, and stress 1
• Bathe in warm (not hot) water for 5-10 minutes, using minimal amounts of mild, non-soap cleansers, followed immediately by emollient application 1
• Provide patient education on disease mechanisms, proper application techniques, and realistic expectations, as comprehensive education reduces disease severity and improves quality of life 1

Mild Atopic Dermatitis

• Use low-to-medium potency topical corticosteroids (hydrocortisone 2.5%, triamcinolone 0.1%, or mometasone 0.1%) applied once or twice daily to active lesions until significantly improved 1
• Alternative first-line options include pimecrolimus 1% cream or crisaborole 2% ointment (PDE-4 inhibitor) for patients who prefer non-steroidal agents 1
• Limit high-potency steroids on the face, neck, and intertriginous areas due to increased risk of skin atrophy; use hydrocortisone 2.5% or alclometasone 0.05% in these sensitive locations 2, 3

Moderate Atopic Dermatitis

• Escalate to medium-potency topical corticosteroids (fluticasone 0.05%, mometasone 0.1%) applied twice daily for 2-4 weeks during flares 1, 2
• Implement proactive maintenance therapy with twice-weekly application of medium-potency topical corticosteroids to previously affected areas for 16-36 weeks after achieving control, which reduces relapse risk by 54% (RR 0.46,95% CI 0.38-0.55) 1, 2
• Add topical calcineurin inhibitors (tacrolimus 0.03-0.1% or pimecrolimus 1%) twice daily as steroid-sparing agents, particularly for facial and intertriginous involvement where long-term steroid use risks atrophy 1, 4
• Consider ruxolitinib cream (JAK inhibitor) as a newer non-steroidal option with moderate-certainty evidence for efficacy 2

Critical Pitfall: Verify Adequate Treatment Before Declaring Failure

• Confirm patients have used at least medium-potency steroids (mometasone 0.1% or fluticasone 0.05%) applied twice daily for a minimum of 2 weeks before deeming topical therapy ineffective 2
• Address "steroid phobia" through education, as non-adherence often masquerades as treatment resistance 3

Severe Atopic Dermatitis

• Initiate high-potency topical corticosteroids (betamethasone dipropionate 0.05%) or very-high-potency agents (clobetasol 0.05%) for trunk and extremities, applied twice daily for 2-4 weeks 2
• Transition to wet-wrap therapy if inadequate response: apply medium-to-high potency corticosteroid, cover with damp cotton layer followed by dry layer, continue for 3-7 days (maximum 14 days in severe cases) 1, 2
• Do not exceed 14 days of wet-wrap therapy without close supervision due to increased systemic steroid absorption risk 2
• Rule out secondary bacterial infection (honey-crusted or weeping lesions suggest Staphylococcus aureus) and treat with systemic antistaphylococcal antibiotics (flucloxacillin or cephalexin) 2
• Consider patch testing if lesions persist despite adequate anti-inflammatory therapy, as allergic contact dermatitis may complicate atopic dermatitis 2, 5

Very Severe or Refractory Atopic Dermatitis

When to Escalate to Phototherapy or Systemic Therapy

Advance to phototherapy or systemic treatment when:

• Disease persists despite 2-4 weeks of optimized topical regimen (including wet-wraps and calcineurin inhibitors) 2
• Body surface area involvement ≥10%, or Investigator Global Assessment ≥3, or significant quality-of-life impairment despite intensive topical therapy 5

Phototherapy (Intermediate Step Before Systemic Agents)

• Narrowband UVB is preferred for extensive or refractory disease in adults and children over 12 years, administered 2-3 times weekly 1
• Phototherapy is not recommended for children younger than 12 years 1

First-Line Systemic Therapy: Biologics and JAK Inhibitors

The treatment landscape has fundamentally shifted: biologics and JAK inhibitors are now first-line systemic agents, relegating traditional immunosuppressants to second-line status. 5

• Dupilumab (IL-4/IL-13 inhibitor) is the preferred first-line systemic agent with strong recommendation and high-certainty evidence; approved for patients aged 6 years and above 1, 5
• Tralokinumab (IL-13 inhibitor) also receives strong recommendation as first-line therapy 5
• Oral JAK inhibitors (upadacitinib, abrocitinib, baricitinib) are strongly recommended as first-line alternatives for patients who prefer oral over injectable therapy 5

Second-Line Systemic Therapy: Traditional Immunosuppressants

Use traditional immunosuppressants only when first-line biologics or JAK inhibitors are unavailable, contraindicated, or insurance-denied. 5

• Cyclosporine 3-5 mg/kg/day (divided twice daily) is the most effective traditional immunosuppressant for rapid disease control; monitor CBC, comprehensive metabolic panel, and blood pressure regularly 5, 6
• Methotrexate 7.5-25 mg once weekly is conditionally recommended; monitor CBC and liver function 5
• Azathioprine 1-3 mg/kg/day is conditionally recommended; perform TPMT testing before initiation and monitor CBC 5
• Mycophenolate mofetil 1.0-1.5 g twice daily is conditionally recommended; monitor CBC and comprehensive metabolic panel 5

Systemic Corticosteroids: Avoid for Maintenance

Systemic corticosteroids should be avoided for maintenance treatment and reserved exclusively for acute severe exacerbations as a bridge therapy (maximum 7-14 days) due to rebound flares after discontinuation. 1, 3, 5

Adjunctive Therapies: Limited Role

• Oral antihistamines provide minimal benefit beyond sedation (~42% response rate) and should not be used routinely for eczema control; consider only for sleep disturbance secondary to pruritus 1, 5
• Bleach baths (0.005% sodium hypochlorite twice weekly) with intranasal mupirocin may reduce infection risk in patients prone to S. aureus colonization 1
• Do not use systemic antibiotics prophylactically in non-infected patients, as they do not prevent flares or reduce colonization 1, 5
• Probiotics and vitamin D have not demonstrated convincing benefits for atopic dermatitis treatment 1

Common Pitfalls to Avoid

• Do not use topical antibiotics long-term due to increased resistance and sensitization risk 1
• Do not use topical antihistamines, as they increase contact dermatitis risk without proven efficacy 1
• Do not use high-potency steroids continuously on the face due to atrophy, telangiectasia, and hypopigmentation risk 3
• Do not commence systemic therapy without first optimizing topical regimens and addressing adherence barriers 5
• Do not overlook contact dermatitis; patch testing is essential in refractory cases 2, 5